Treatments for rosacea

Cochrane: Which treatments are effective for rosacea? Rosacea is a common skin condition causing flushing, redness, red pimples and pustules on the face, and should not be confused with acne. Dilated blood vessels may appear near the surface of the skin (telangiectasia). It can also cause inflammation of the eyes or eyelids, or both (ocular rosacea). Some people can develop a thickening of the skin, especially of the nose (rhinophyma). Although the cause of rosacea remains unclear, a wide variety of treatments are available for this persistent (chronic) and recurring and often distressing disease. These include medications applied directly to the skin (topical), oral medications and light-based therapies.
We wanted to discover how people assessed their treatments: if the treatments changed their quality of life, if they saw changes in their condition and if there were side effects. From the doctors, we wanted to discover whether treatments changed the severity of rosacea, as well as how long it took before symptoms reduced and reappeared.


We reviewed 106 studies (up to July 2014) which included 13,631 people with moderate to severe rosacea. Most were between 40 and 50 years old, with more than twice as many women as men. Most studies lasted between eight to 12 weeks, with the longest lasting 40 weeks. The majority of people in these studies suffered from two rosacea subtypes, the subtype with pimples and pustules, or the subtype that causes flushing and persistent redness.
Of the 106 studies, 66 reported that they received funding, mainly by pharmaceutical companies. We were confident funding did not affect the results in 56 of these studies but had concerns about the remaining 10.


Most of the treatments appeared to be effective in treating rosacea. Almost half of the studies reported how people assessed their treatments. Only 11 assessed changes to quality of life. Almost all studies reported side effects, although this information was often limited. Studies mostly evaluated changes in the number of pimples and pustules, and redness. Only five studies included ocular rosacea. None included the rare variant called 'granulomatous rosacea'.
 
Topical treatments
Two separate treatments, metronidazole and azelaic acid, were effective and safe in reducing rosacea symptoms. Improvements tended to appear after three to six weeks. With metronidazole, very few people experienced mild itching, skin irritation and dry skin. For some, azelaic acid caused mild burning, stinging or irritation. More research is needed to conclude which of these two treatments is best.
Ivermectin, a new treatment, was more effective than placebo and slightly more effective than metronidazole. Another newly registered treatment called brimonidine, especially for reducing redness, was shown to work up to 12 hours after being applied.
 
Oral treatments
Antibiotics such as tetracycline, a low dose of doxycycline or a low dose of minocycline reduced the number of pimples and pustules. Low dose doxycycline (40 mg) was likely as effective as 100 mg, but with much fewer side effects of diarrhoea and nausea. Azithromycin may be as effective as 100 mg doxycycline, but only one study addressed this treatment and better quality studies are needed to confirm this.
A low dose of isotretinoin (0.3 mg/kg), a vitamin A-related drug, appeared to be slightly more effective than 50-100 mg doxycycline for treating pimples and pustules. However, extra precautions need to be taken regarding contraception in women of childbearing age as this drug is known to cause malformations in the foetus.
 
Light-based therapies
Laser therapy and intense pulsed light therapy were both effective for the treatment of telangiectasia, but the studies examining these treatments only reported limited data.
 
Rosacea of the eyes or eyelids, or both (ocular rosacea)
Better quality studies are required on ocular rosacea, though ciclosporin 0.05% ophthalmic emulsion appeared to be more effective than artificial tears.


We rated the quality of the evidence for several outcomes as very low to high. There was high quality evidence for azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin. The lower quality evidence for other treatments was mostly because there were few people in the studies, making the results less precise, and the lack of blinding (people knew which treatments they were receiving).

 

Authors' conclusions: 

There was high quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate quality evidence was available for topical metronidazole and oral tetracycline. There was low quality evidence for low dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea. Time needed to response and response duration should be addressed more completely, with more rigorous reporting of adverse events. Further studies on treatment of ocular rosacea are warranted.